The views of hospital administrators, doctors and payers on cost-efficiency in surgery do not necessarily coincide. The difference between charges and cost and the particularities of the financing mechanisms may induce situations in which savings for the society as a whole result in financial loss for the hospital. Examples are in the use of stapling devices, in ambulatory surgery, in endoscopic surgery: they all result in better quality of care and decreasing health care cost for society; they often induce, however, a not compensated increase in hospital costs. Surgeons and administrators can find each other in a common concern for optimizing efficiency. This asks for an agreement regarding the techniques and equipment to be used, and regarding the necessary minimum case load. This paper presents the case of the endoscopic cholecystectomy as an example. The second part of the paper deals with various aspects of quality and cost of the hospital product. It warns against purely technology-inspired investments which entail a risk for overconsumption and inappropriate use. It also asks for attention for the educational cost and for the continuing running cost which may result from capital investment decisions. Finally it underscores the role that surgeons can play in reducing the running cost, by paying attention to a smoother organisation of the OR activities and to the choice of materials, consumables and pharmaceuticals.